On January 31, 2014 a
Complaint,Petition
was filed
involving a dispute between
and
in the District Court of Pinellas County.
Preview
Case Number: 14-000735-SC
***ELECTRONICALLY FILED 1/31/2014 2:43:49 PM: KEN BURKE, CLERK OF THE CIRCUIT COURT, PINELLAS COUNTY***
Filing # 9779372 Electronically Filed 01/31/2014 02:43:51 PM
ASSIGNMENT OF BENEFITS
LIENS AND DIRECT PAYMENT AUTHORIZATION
MEDICAL PROVIDER: MRI ASSOCIATES OF PALM HARBOR, INC,
D/B/A PALM HARBOR MRI
32615 US HWY 19 N. #4
PALM HARBOR, FL 34684
INSURANCE COMPANY: ‘i ( ( wn +E UN i )
For and in consideration of the above-mentioned provider agreeing to pursue my insurance provider for payment
of benefits due me and not requiring prepayment for services, I hereby irrevocably assign to the aforementioned
medical provider (the ‘Provider’) any Personal Injury Protection benefits I may have in accordance with Florida
Statute 627.736(3). This includes any benefits from my insurance company or any other entity that may be
responsible for expenses incutred, but only to the extent of treatment rendered by provider. I authorize the
‘Provider’ to prosecute said action, and collect legal expenses as they see fit. THIS DOCUMENT
CONSTITUTES AN ASSIGNMENT OF BENEEITS. I hereby further give a lien to the ‘Provider’ against any
and all insurance benefits names hereon, and any and all proceeds of any settlement, judgment or verdict which
may be paid to me asa result of the injuries or illness for which I have been treated by the ‘Provider’. This is to act
as an irrevocable assignment of my sights and benefits to the extent of the services provided. I agree to cooperate
with the ‘Provider’ and any attorney that the ‘Provider’ chooses, and to do all things reasonable to effect payment
of the bills by the insurance company to the ‘Provider’ including, but not limited to, disclosing patient's medical
condition and treatment. This assignment concerns only the bills for the provider and those costs (including, but
not limited to attomey’s fees, court costs and interest) necessary to procuring payment from the above-named
insurance company, etc. This assignment is not intended to assign any other causes of action thar may belong to
the undersigned patient. I agree to pay any applicable deductible or co-payment not covered by the PIP insurance
coverage. I understand that this is a benefit and convenience to me in that the ‘Provider’ will pursue collection
against the insurance company on my behalf. I hereby instruct and direct my insurance company to pay my
benefits by check, made payable to and mailed co the ‘Provider’ at the address listed above. If my current policy
prohibits direct payment to doctors, then I hereby instruct and direct my insurance company to make the check
payable to me and mail ir to the ‘Provider’ at the address listed above. If thus ‘Provider’ is providing medical care
related to an auto accident, ‘Provider’ is charging a reasonable fee for necessary care selated to the accident,
‘Provider’ is charging a reasonable fee for necessary care related to the accident, and these bills should be paid to
the full extent of the benefits available under my policy of insurance. If any portion of any charge for these services
is either reduced or denied in whole or in part, that my insurance company is to place funds equal to the amount
of the reduced or denied charge into escrow. My insurance company is to hold the escrowed funds for the
“Provider’, until such time as all escrowed funds are paid to ‘Provider’, or “Provider’ instructs my insurance
company that ‘Provider is no longer making any claim to the escrowed funds. Furthermore, I hereby give the
‘Provider’ limited power of attorney to endorse/sign my name on any and all checks for payment to the ‘Provider’.
This agreement is intended to serve as an assignment of the patient's rights and benefits under his/her
aforementioned insurance policy in favor of the "Provider’. If any language within this agreement has the effect of
invalidating this assignment that language shall be deemed void and the assignment shall remain in full force and
effect. A photocopy of this assignment shall be considered as effective and valid as the original.
f sieht s—
af 13
‘Witness Signucure Date
Patient Si gaprd L 4
Document Filed Date
January 31, 2014
Case Filing Date
January 31, 2014
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Case Number: 14-000735-SC ***ELECTRONICALLY FILED 1/31/2014 2:43:49 PM: KEN BURKE, CLERK OF THE CIRCUIT COURT, PINELLAS COUNTY*** Filing # 9779372 Electronically Filed 01/31/2014 02:43:51 PM ASSIGNMENT OF BENEFITS LIENS AND DIRECT PAYMENT AUTHORIZATION MEDICAL PROVIDER: MRI ASSOCIATES OF PALM HARBOR, INC, D/B/A PALM HARBOR MRI 32615 US HWY 19 N. #4 PALM HARBOR, FL 34684 INSURANCE COMPANY: ‘i ( ( wn +E UN i ) For and in consideration of the above-mentioned provider agreeing to pursue my insurance provider for payment of benefits due me and not requiring prepayment for services, I hereby irrevocably assign to the aforementioned medical provider (the ‘Provider’) any Personal Injury Protection benefits I may have in accordance with Florida Statute 627.736(3). This includes any benefits from my insurance company or any other entity that may be responsible for expenses incutred, but only to the extent of treatment rendered by provider. I authorize the ‘Provider’ to prosecute said action, and collect legal expenses as they see fit. THIS DOCUMENT CONSTITUTES AN ASSIGNMENT OF BENEEITS. I hereby further give a lien to the ‘Provider’ against any and all insurance benefits names hereon, and any and all proceeds of any settlement, judgment or verdict which may be paid to me asa result of the injuries or illness for which I have been treated by the ‘Provider’. This is to act as an irrevocable assignment of my sights and benefits to the extent of the services provided. I agree to cooperate with the ‘Provider’ and any attorney that the ‘Provider’ chooses, and to do all things reasonable to effect payment of the bills by the insurance company to the ‘Provider’ including, but not limited to, disclosing patient's medical condition and treatment. This assignment concerns only the bills for the provider and those costs (including, but not limited to attomey’s fees, court costs and interest) necessary to procuring payment from the above-named insurance company, etc. This assignment is not intended to assign any other causes of action thar may belong to the undersigned patient. I agree to pay any applicable deductible or co-payment not covered by the PIP insurance coverage. I understand that this is a benefit and convenience to me in that the ‘Provider’ will pursue collection against the insurance company on my behalf. I hereby instruct and direct my insurance company to pay my benefits by check, made payable to and mailed co the ‘Provider’ at the address listed above. If my current policy prohibits direct payment to doctors, then I hereby instruct and direct my insurance company to make the check payable to me and mail ir to the ‘Provider’ at the address listed above. If thus ‘Provider’ is providing medical care related to an auto accident, ‘Provider’ is charging a reasonable fee for necessary care selated to the accident, ‘Provider’ is charging a reasonable fee for necessary care related to the accident, and these bills should be paid to the full extent of the benefits available under my policy of insurance. If any portion of any charge for these services is either reduced or denied in whole or in part, that my insurance company is to place funds equal to the amount of the reduced or denied charge into escrow. My insurance company is to hold the escrowed funds for the “Provider’, until such time as all escrowed funds are paid to ‘Provider’, or “Provider’ instructs my insurance company that ‘Provider is no longer making any claim to the escrowed funds. Furthermore, I hereby give the ‘Provider’ limited power of attorney to endorse/sign my name on any and all checks for payment to the ‘Provider’. This agreement is intended to serve as an assignment of the patient's rights and benefits under his/her aforementioned insurance policy in favor of the "Provider’. If any language within this agreement has the effect of invalidating this assignment that language shall be deemed void and the assignment shall remain in full force and effect. A photocopy of this assignment shall be considered as effective and valid as the original. f sieht s— af 13 ‘Witness Signucure Date Patient Si gaprd L 4